Cost-Effectiveness of a Chronic Care Model for Frail Older Adults in Primary Care: Economic Evaluation Alongside a Stepped-Wedge Cluster-Randomized Trial

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Abstract

OBJECTIVES:

To evaluate the cost-effectiveness of the Geriatric Care Model (GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care.

DESIGN:

Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial.

SETTING:

Primary care (35 practices) in two regions in the Netherlands.

PARTICIPANTS:

Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147).

INTERVENTION:

The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs.

MEASUREMENTS:

Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) physical (PCS) and mental component summary (MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D.

RESULTS:

Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = −$488–1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0–100). For all other outcomes the probability of the intervention being cost-effective was low.

CONCLUSION:

Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended.

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